Cite as: Humphrey, N. & Wigelsworth, M. (2016). Making the case for universal school-based mental health screening. Emotional and Behavioural Difficulties [invited article], 21, 22-42.
Making the case for universal school-based mental health screening
Neil Humphrey and Michael Wigelsworth
Manchester Institute of Education
School of Environment, Education and Development
Ellen Wilkinson Building
Oxford Road
University of Manchester
M13 9PL
0161 275 3404
Abstract
Mental health difficulties affect 1 in 10 children and adolescents,andup to half of adult cases begin during the school years. The individual and societal impacts of such difficulties are huge, and includepoorer quality of life, lost economic productivity,destabilisation ofcommunities, and high rates of health, education and social care service utilisation. Using early intervention and prevention in schools as a central component of a co-ordinated response to this emergentpublichealth crisis makes good sense.Schools play a central role in the lives of children and their families, and their reach is unparalleled. It has been argued that truly comprehensive and effective mental health promotion in schools requires a universal screening component, butthis is a controversial proposition. In this article we explore some of theopportunities and challenges posed by such a system. In doing so we critically assess international literature on socialvalidity (e.g. acceptability, feasibility and utility), definition and conceptualisation (e.g. whatdo we mean by ‘mental health’ and related terms?), design and implementation (e.g. planning, toolselection, linking to referral and intervention systems), psychometric considerations (e.g. are available instruments reliable and valid?), diversity (e.g. taking into account cultural variation) and costs and benefits (e.g. are the human, financial and material costs of universal screening justified by the improvements in provision and outcomes they bring?). We conclude by presenting a vision for a school-based system that takes into account these important factors.
Keywords: mental health, universal, screening, assessment, schools
Making the case for universal school-based mental health screening
Introduction
Mental health difficulties (MHDs) are changes in thinking, mood and/or behaviour that impair functioning (Murphey, Barry, & Vaughn, 2013). In the two major classification systems used in the field (International Classification of Diseases and the Diagnostic and Statistical Manual) a distinction is drawn between internalising (e.g. anxiety and mood disorders) and externalising (e.g. conduct and hyperkinetic disorders) problems (Tyrer, 2014). 1 in 10 children and young people experience clinically significant MHDs (Green, McGinnity, Meltzer, Ford, & Goodman, 2005), and 50% of adult cases originate in childhood or adolescence (Belfer, 2008). Children who experience such difficulties are less likely to attend and achieve their potential in school (Colman et al., 2009) and more likely to be unemployed as adults (Farrington, Healey, & Knapp, 2004). Over the life course, the individual and societal impacts of MHDs are huge, and can include reduced quality of life, lost economic productivity, destabilization of communities, and high rates of health, education and social care utilization (Belfer, 2008). In financial terms, the annual cost is around £105 billion annually in England (Centre for Mental Health, 2010), of which more than £20 billion is spent on health and social care (more than double the annual cost of cancer diagnosis and treatment - Williams, 2013). By 2030, depression alone will yield the highest disease burden in high-income countries, accounting for nearly 10% of disability-adjusted-life-years (Mathers & Loncar, 2006). It is our contention that this is an emerging public health crisis. Although the prevalence of MHDs in childhood and adolescence stabilised in the early years of the new millennium following a sharp rise in previous decades (Maughan, Collishaw, Meltzer, & Goodman, 2008), spending reductions child and adolescent mental health services (CAMHS) in the last five years (Buchanan, 2015) mean that the high proportion of unmet need discussed later in this article will continue to rise as eligibility/referral thresholds for service access inevitably increase.
School is an ideal setting in which to identify those at risk of developing MHD and intervene early to address problems before they become deeply entrenched. The nature of schooling provides a critical opportunity to effect positive change – it is universal, begins early in life and entails periods of prolonged engagement with children and young people (totaling around 15,000 hours - Rutter, Maughan, Mortimore, Ouston, & Smith, 1979) during which effective intervention strategies can be implemented. In most education systems, a tiered approach to intervention is evident (Weare & Nind, 2011). Universal mental health provision is designed to reach all children and prevent problems before they occur by equipping children with the intra- (e.g. self-regulation) and inter-personal (e.g. empathy) skills that can help them to be more resilient to the onset of MHD during difficult periods in their lives. An example of this kind of provision is the Second Step social and emotional learning curriculum (Committee for Children, 2011). For children with nascent MHD, additional support may be required through selective/targeted interventions that seek to prevent the progression of symptoms. At this level of provision, interventions start to become differentiated according to the nature of the difficulties experienced by children. The small group work component of the social and emotional aspects of learning (SEAL) programme (Department for Education and Skills, 2006) provides a useful illustration. Finally, indicated interventions are designed for children identified as having prodromal or established MHD. At this level of provision, interventions are typically more intensive, lengthy, and often involve health, social or specialist community services (Shucksmith, 2007). A school-based example can be seen in Bloomquist, August, and Ostrander's (1991) cognitive-behavioural intervention for children with ADHD.
Numerous systematic reviews and meta-analyses attest to the fact that high quality, well implemented school-based mental health interventions can effect meaningful change for children and young people (e.g. Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011; Shucksmith, 2007; Sklad, Diekstra, De Ritter, Ben, & Gravesteijn, 2012; Weare & Nind, 2011; Wilson & Lipsey, 2007). There is also broad agreement that an integrated approach to provision that offers a synthesis of universal, targeted and indicated interventions is likely to be the most effective model for schools, offering as it does increased intervention exposure for those who need it most, the possibility of additive or multiplicative effects brought about through the interaction of different interventions, improved sustainability, and increased implementation quality (Domitrovich et al., 2010).
The case for universal mental health screening in schools
In spite of the substantial and growing evidence base for mental health provision in schools, there is still significant room for improvement in the system. For example, the majority of schools in England report using approaches to intervention that have no evidential base (Vostanis, Humphrey, Fitzgerald, Wolpert, & Deighton, 2013). Additionally, despite the rhetoric of the importance attributed to mental health, education policy has increasingly encouraged schools to maximise students’ academic attainment at the expense of their broader wellbeing and health (Bonell et al., 2014), an issue to which we return later in this article. However, unmet need is perhaps the most significant of the problems to be addressed. Kelvin (2014) reports that up to 75% of children in the UK who experience significant MHD do not access the support that they need, whether in the context of education, health or social care services. A similar proportion of unmet need is evident in other countries such as the USA (Dvorsky, Girio-Herrera, & Owens, 2014).
While this cannot solely be attributed to lack of effective early identification (for example, referral thresholds to CAMHS are increasingly stringent, and there are inequalities in service access among certain marginalized groups, such as those in black and minority ethnic communities), it is undoubtedly a major contributory factor, and on this basis we argue that a critical step-change in methods and practices is required. Indeed, this is one of the key tenets of the Department of Health’s recently published Future in Mind strategy document (Department of Health, 2015), which argues for improvements in, “early identification of need, so that children and young people are supported as soon as problems arise to prevent more serious problems developing” (p.33). Despite some recent advances (for example, the 2014 launch of Mind Ed, a Department of Health web portal designed to help adults working with children and young people spot the early signs of MHD), we still arguably operate according to two inefficient and ineffective models of service delivery. The first, ‘refer-test-place’ (Dowdy, Ritchey, & Kamphaus, 2010), involves children with MHD being referred to a given professional (for example, an educational psychologist or mental health worker), who assesses their needs and provides advice regarding appropriate targeted/indicated provision. The second, what Glover and Albers (2007) call the ‘wait to fail’ model, involves children and young people’s MHD coming to the attention of education, care and/or health service professionals as the result of events that reflect deeply entrenched problems (for example, being permanently excluded from school or coming into contact with the criminal justice system). Both models are fundamentally flawed because they are highly variable and result in under-referral (thus undoubtedly contributing to the unmet need statistics noted above) and late-referral (meaning that critical opportunities for early intervention have been missed) (Dvorsky et al., 2014). Furthermore, they operate against a backdrop of major cuts to child mental health services in two-thirds of Local Authorities since 2010 (Young Minds, 2013), which have had the effect of increasing pressure on schools to ‘pick up the pieces’ (O’Hara, 2014). At a broader level, the current state of affairs in children’s mental health can be seen as a reflective of the problems associated with societal inequality. Wilkinson and Pickett (2010) highlight international evidence of the inverse relationship between child wellbeing and income inequality. The UK provides a useful case in point – extremely high levels of income inequality, juxtaposed against child wellbeing levels that were the lowest recorded among 21 developed counties in 2007 (UNICEF, 2007)[1].
So, what is to be done? It has been argued that a critical prerequisite to providing effective school-based prevention and intervention services is the adoption of a population-based approach embodied by a universal screening model. In such a system, all members of the student population in a school undergo brief assessments (which may be informed by teachers, parents and/or students themselves) designed to identify those at risk of developing MHD (Dowdy et al., 2010; Dvorsky et al., 2014; Glover & Albers, 2007). The logic is simple: “before intervention can occur mental health problems must be identified” (Williams, 2013, p.5478), and periodic universal screening beginning as early as possible means that MHD can be identified before they reach clinically significant levels. Dvorsky et al (2014) propose three key benefits of such a system. First, by definition, universal screening means that all children and young people are assessed. Theoretically, this should have the effect of reducing the number of those at-risk being overlooked compared to the existing methods noted above. Second, universal screening provides a baseline for future monitoring and assessment. This means that a more data-driven approach to mental health provision in schools can be adopted. Third, universal screening can offer significant cost-savings over time. The basic logic here is that universal screening should lead to earlier intervention for emergent MHD, which is less intensive and expensive than indicated interventions for more severe or entrenched problems. However, despite these apparent benefits, universal mental health screening is extremely rare. For example, only 2% of schools in the USA use this approach as part of their routine practice (Romer & McIntosh, 2005). This contrasts sharply with screening for physical health indicators (e.g. vision, hearing), which have been universally assessed for decades (Dowdy et al., 2010; Williams, 2013). What accounts for this discrepancy? It may reflect the fact that mental health has traditionally not been given equal weight to physical health in public policy (H. M. Government, 2010). The stigma associated with mental health is also a likely contributory factor (Dowdy et al., 2010; Evans-Lacko et al., 2014). In truth, there are multiple challenges that mean universal school-based screening for MHD is ‘easier said than done’, and through the course of this article we discuss these in addition to the opportunities it can provide.
Social validity
Social validity refers to the value and social importance attributed to a given innovation by those who are direct or indirect consumers of it (Hurley, 2012; Luiselli & Reed, 2011). In this case, they are teachers and other school staff, parents, pupils and external education, health and social care professionals. Social validity is a critical but often overlooked consideration when new initiatives are launched in education. Adapting Wolf's (1978) classic taxonomy, it can be thought of in terms of acceptability (e.g. are the intended outcomes of an innovation wanted, needed, and/or socially significant?), feasibility (e.g. are the procedures employed to achieve the intended outcomes of the innovation considered to be acceptable?) and utility (e.g. are the outcomes of the innovation considered to satisfactory?). We begin our discussion of universal school-based screening for MHD on this issue because it is so fundamental. Without demonstrable social validity, innovations in education or elsewhere are unlikely to be widely adopted. Currently, “there is a dearth of information regarding the acceptability of screeners and screening process, along with the social importance of the effects of screening” (Dvorsky et al., 2014, p.307). However, that which is available provides extremely useful insights.
In terms of acceptability, there is little doubt that the goal of preventing MHD and promoting wellbeing among children and young people is considered to be socially important among the various stakeholders noted above. However, there are some concerns about the concept of universal screening as a means through which to achieve this. Among these, the idea that it will be a stigmatising process is common (Williams, 2013). At first, this may seem like an oxymoron – surely a universal approach would be destigmatising as no single person or group are singled out? However, concerns remain about the problem-focused nature of assessments (see later section on conceptualisation of mental health) and the possible later consequences in terms of ‘typing’ (e.g. the screening results trigger the application of a prototype for MHD that then acts as a filter through which the child’s future behaviour is observed). This is a particular issue in ‘false positive’ cases, where a screening instrument categorises a child incorrectly as at-risk. Sensitive handling of screening, identification, referral and intervention processes is therefore fundamental, alongside explicit efforts to reduce stigma that may include provision of mental health literacy initiatives for staff (e.g. Kutcher, Wei, McLuckie, & Bullock, 2013) and students (e.g. Wei, Hayden, Kutcher, Zygmunt, & McGrath, 2013).